Understanding the No Surprises Act and your patient rights is essential for protecting yourself from unexpected medical billing. ATX Orthopedics is committed to full transparency.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your healthplan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medicalbills could cost thousands of dollars depending on the procedure or service.

You’re protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharingamount (such as copayments, coinsurance, and deductibles). You can’t be balance billed forthese emergency services. This includes services you may get after you’re in stable condition,unless you give written consent and give up your protections not to be balanced billed for thesepost-stabilization services.[Insert plain language summary of any applicable state balance billing laws or requirements ORstate-developed language as appropriate]

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’tbalance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You alsoaren’t required to get out-of-network care. You can choose a provider or facilityin your plan’s network.

Texas Protections Against Balance Billing

Texas law protects patients from surprise medical bills in many situations.

If you have a health plan regulated by the Texas Department of Insurance (including most fully insured plans, as well as certain plans such as TRS and ERS), you are protected from balance billing for:

• Emergency care
• Services provided at in-network facilities
• Certain out-of-network services covered under Texas law

This means you cannot be billed for the difference between your provider’s charges and the amount paid by your insurance, beyond your applicable deductible, copayment, or coinsurance.

In these situations, providers and insurers resolve payment disputes through a state-administered process.

Our Practice’s Commitment to You

Regardless of your insurance plan, our practice is committed to providing:

• Clear, upfront information about your costs
• Billing your insurance directly
• Limiting your financial responsibility to your applicable cost-sharing whenever possible

When insurance underpays for covered services, we pursue additional reimbursement directly with the insurer through:

• Texas dispute resolution processes (when applicable)
• Federal arbitration under the No Surprises Act

Patients are not involved in these processes and will not receive unexpected balance bills from our practice.

Questions About Your Coverage?

If you have questions about your protections under Texas law or your specific plan:

• Contact your insurance provider
• Visit the Texas Department of Insurance website
• Or contact our office—we’re happy to help explain your benefits

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance,and deductible that you would pay if the provider or facility was in-network). Your healthplan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services inadvance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay anin-network provider or facility and show that amount in your explanation ofbenefits.
  • Count any amount you pay for emergency services or out-of-network servicestoward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, contact:

• Federal (No Surprises Act):
  Centers for Medicare & Medicaid Services
  1-800-985-3059
  https://www.cms.gov/nosurprises
• Texas Protections:
  Texas Department of Insurance
  1-800-252-3439
  https://www.tdi.texas.gov